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By Jeanette Eklund,
Product Manager for Revenue Cycle Management, Brightree

The Centers for Medicare & Medicaid Services (CMS) have recently proposed significant changes to the National Coverage Determination (NCD) for home oxygen use that, if implemented, will impact how HME businesses document patient medical need and track equipment.

While we can assume that many factors influenced the decision to review and update Medicare oxygen benefits, COVID-19 shed light on one of the biggest proposed changes to the NCD: coverage for acute conditions requiring home oxygen treatment. CMS has also proposed eliminating the need for a Certificate of Medical Necessity and trial of alternative therapies to qualify for oxygen coverage.

These changes will benefit patients by expanding covered home therapy options and empowering physicians to determine medical necessity for treatment. That being said, providers will need to be prepared to adopt new documentation practices and consider how their HME business will respond should the changes go into effect. CMS accepted public comments until August 1, 2021 and will release its decision after reviewing comments on September 30, 2021.

Let’s outline the major points of the proposed oxygen NCD updates from CMS, and then explore the possible impacts for HME providers.

What changes are coming to the Medicare oxygen benefit?

The potential NCD changes primarily focus on providing coverage for acute conditions and relieving supplier burden. Here are the most important highlights for HME providers:

Removal of the Certificate of Medical Necessity (CMN) requirement

Currently, physicians need to sign a CMN for each patient requiring oxygen treatment in order to file a claim with Medicare for their equipment. Since suppliers already obtain a written order from a healthcare practitioner and have medical records proving the medical necessity of the equipment, the CMN is just another piece of paper for suppliers to chase and potential roadblock to treatment. Eliminating the need for a CMN would reduce the documentation burden for suppliers and physicians and increase efficiencies across the board.

Expanded coverage for acute conditions

Historically, Medicare would only approve home oxygen equipment for patients diagnosed as in a “chronic stable state.” This seriously limited the ability of patients with acute conditions that could benefit from oxygen therapies from getting the treatment they needed. During the COVID-19 pandemic, Medicare opened up its coverage guidelines to include all patients diagnosed with COVID-19 – an acute condition – in need of oxygen therapy.

This was a turning point for CMS, and it is now proposing to continue to cover oxygen equipment for acute conditions (such as cluster headaches). In the proposal, CMS states that “lessons learned from the COVID-19 public health emergency have compelled us to review NCD 240.2 to ensure that our coverage policies do not impede patient access to oxygen in appropriate circumstances.” This is a big win for patients and presents a unique opportunity for HME providers to expand their patient base and begin providing equipment for short-term use.

Removal of the trial of alternative therapies before oxygen coverage

Medicare patients currently receiving oxygen therapy benefits must first prove that they have tried alternative therapies in order to meet coverage criteria. CMS believes that more trust should be put in the treating practitioner to determine whether oxygen is medically necessary and reasonable. Practitioners will be given more power to use their discretion when evaluating alternative treatment options and ordering oxygen therapy. This will relieve suppliers from having to search the medical record for proof of alternative therapies tried for each patient and ensures that patients in need will receive the right treatment for the best outcomes.

Read the full proposal from CMS here.

What do HME providers need to know about the oxygen NCD proposal?

While these changes would be overwhelmingly beneficial for patients and providers alike, HME businesses will need to consider how they will adapt their workflows to accommodate new demand and make sure they remain compliant with CMS requirements.

If the CMN requirement is eliminated, providers will still need to make sure they validate the medical records of every patient. If an organization were ever audited for a claim, it may become more subjective based on contractor discretion. Providers should verify they have a standard written order that meets CMS guidelines and maintain thorough records to support patient need. One way to make sure your intake process remains compliant with changing requirements is to use a flexible, automated intake solution that allows you to easily update and customize patient qualification criteria.

Additionally, HME providers will have the opportunity to take on acute patients – but this could require implementing new systems to deliver, monitor, and retrieve equipment at a much faster pace. Though oxygen equipment for chronic patients has always required swift delivery, you may now have a higher turnover as acute patients complete their treatment in shorter amounts of time. Will your current warehouse, ongoing compliance, and billing operations be able to handle an influx of acute condition patients that require more monitoring and a shorter rental life? According to the CMS proposal, if the patient’s need for oxygen extends past 90 days, HME providers will need to make sure they obtain medical records from the physician that prove this need. Automated solutions (like those from Brightree) can help you adapt and scale to a larger, changing patient base and feel confident that you’ll be able to maximize the potential of your business in light of these proposed changes.

This proposal represents an exciting shift ahead for Medicare patients and providers, and the burden surrounding prescribing oxygen therapies may soon be reduced. To learn more about how you can prepare to enhance your operations and provide efficient solutions for oxygen patients, get in touch with a Brightree representative today.

Jeanette Eklund, Product Manager for Revenue Cycle Management, Brightree

Jeanette converts big ideas into roadmaps to success for products supporting the Brightree RCM team. She has worked in various aspects of the HME software industry for the last 16 years, including system implementations, training, support, and account management. She has spent the last 7 years in product management, and 3 of those years were spent as the Brightree BMS Product Manager. She is passionate about creating simple software solutions that solve complex user problems.

Jeanette Eklund Product Manager for Revenue Cycle Management, Brightree

Jeanette Eklund, Product Manager for Revenue Cycle Management, Brightree

Jeanette converts big ideas into roadmaps to success for products supporting the Brightree RCM team. She has worked in various aspects of the HME software industry for the last 16 years, including system implementations, training, support, and account management. She has spent the last 7 years in product management, and 3 of those years were spent as the Brightree BMS Product Manager. She is passionate about creating simple software solutions that solve complex user problems.